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The   Cure  of  Rupture 

BY 

Paraffin  Injections 

BY 

CHARLES  C.  MILLER,  M.  D. 


Comprising  a  description  of  a  method  of  treatment  destined 

to  occupy  an  important  place  as  a  cure  for  rupture 

owing  to  the  extreme  simplicity  of  the  technic 

and  its  advantages  from   an   economic 

standpoint 


CHICAGO 

Oak  Printing:  Co.,  9  Wendell  St. 

1908 


1^T)-U1 


Copyriglit   1S08 
By  Charles  C.  Miller 


FOREWORD. 

In  taking  up  the  description  of  the  injection 
of  paraffin  for  the  cure  of  hernia  a  number  of 
remarks  of  a  prefatory  nature  are  called  for, 
as  it  is  necessary  to  justify  a  treatment  which 
has  come  in  for  a  considerable  censure  from 
surgeons  who  have  had  no  experience  with  the 
method  and  who  have  judged  solely  from  a  few 
mishaps  which  came  to  their  attention  and 
which  in  no  way  permit  of  an  accurate  estimate 
of  the  treatment. 

Paraffin  injections  have  been  in  use  only  a 
few  years.  When  first  introduced  their  value 
for  the  closing  of  hernial  openings  was  men- 
tioned. At  the  time  the  factors  which  made 
injections  valuable  for  such  treatment  were 
not  appreciated.  Paraffin  was  merely  looked 
upon  as  an  agent  which  might  be  used  to  plug 
a  hernial  opening  and  such  plugging  of  a  her- 


nial  opening  is  impracticable  without  histologic 
changes  in  the  tissues  to  cause  permanent  clos- 
ure of  the  hernial  passage. 

The  need  which  Paraffin  fulfills  in  Hernia. 

Paraffin  has  a  tendency  to  promote  the  forma- 
tion of  connective  tissue  and  in  hernial  cases 
there  is  invariably  a  state  of  the  parts  which 
will  be  benefitted  by  the  throwing  out  of  con- 
nective tissue  in  the  neighborhood  of  the 
deficiency  which  gives  passage  to  the  hernial 
contents.  Besides  this  production  of  connective 
tissue,  the  occlusion  of  the  hernial  sac  and  glue- 
ing together  of  the  walls  of  the  hernial  canal, 
the  plugging  and  supportive  action  of  a  material 
like  paraffin  is  likely  to  be  in  a  measure  useful 
as  the  paraffin  does  not  lie  in  the  tissues  as  a 
single  mass,  but  it  is  traversed  by  trabeculae 
of  connective  tissue. 


OPERATION  WITHOUT  ANESTHESIA  A 
GREAT    ADVANTAGE. 

Injections  of  paraffin  are  accomplished  with 
such  ease  without  anesthesia  that  the  mere  fact 
that  a  hernia  is  curable  without  the  taking  of 
an  anesthetic  is  an  advantage  on  the  part  of 
the  paraffin  method  which  will  be  highly  appre- 
ciated by  a  very  large  percentage  of  patients 
suffering  from  rupture. 

It  is  safe  to  say  that  for  eYery  patient  suffer- 
ing from  rupture  who  is  willing  to  submit  to 
the  cutting  operation  four  or  five  patients  will 
be  met  who  are  afraid  to  submit  to  such  opera- 
tion because  a  general  anesthetic  is  to  be  taken. 

Applicable  in  the  Physician's  Office. 

Paraffin  injections  may  be  made  in  the  physi- 
cian's office  and  there  is  no  condition  produced 
which  renders  it  difficult  for  the  patient  after 
injection  to  go  to  his  home,  if  he  must  not 
travel  more  than  a  moderate  distance.  The  re- 
action may  be  such  as  to  make  it  advisable  for 


the  patient  to  remain  quiet  for  a  week  or  even 
two  weeks,  though  this  is  exceptional,  yet  such  , 
avoidance  of  exertion  is  not  looked  upon  in  the 
same   light   by   patients   as   two   weeks     strict 
confinement  to  bed. 

The  probability  of  escaping  confinement  is  a 
great  incentive  to  a  patient  to  submit  to  an 
injection,  when  he  would  refuse  operation. 

Injections  are  not  necessarily  imphysiologic 
as  the  sufferer  from  a  hernia  has  a  physiologic 
deficiency  which  the  paraffin  accurately  fills 
with  normal  connective  tissue. 

The  dangers  of  injection  can  be  eliminated. 
The  technic  is  not  difficult  even  when  all  pre- 
cautions are  taken. 

There  is  less  likelihood  of  suppuration  follow- 
ing the  injection  treatment  than  following  the 
cutting  operation. 

The  consequences  of  suppuration  are  less.  If 
suppuration  occur  after  the  open  operation 
failure  is  likely,  not  to  mention  the  danger  of 
peritonitis.  Such  is  not  the  case  following 
injection,    and    while    consequences    are    less 


serious  suppuration  is  avoided  much  more  read- 
ily  than   following   the   open   operation. 

Only  the  operator  thoroughly  acquainted 
with  the  manner  of  disposition  of  paraffin 
should  attempt  the  injection  of  hernia. 

Simplicity. 

To  the  skilled  operator  the  injection  treat- 
ment is  exceedingly  simple  and  the  injection 
method  must  always  be  far  more  simple  than 
the  open  operation  can  ever  become. 

A  hernia  can  be  injected  without  haste  in 
from  two  to  four  minutes. 

An  assistant  is  of  no  use. 

The  open  operation  cannot  be  performed 
without  the  aid  of  several  trained  assistants, 
and  without  elaborate  and  expensive  prepara- 
tions, it  is  not  feasable  as  anything  but  a  hos- 
pital operation. 

Hospital  surgeons  may  be  expected  to  con- 
demn the  injection  treatment  of  hernia,  as  it 
will  open  to  thousands  of  the  profession  a  field 


which  has  hitherto   been  monopolized  by  the 
snrgeons  with  hospital  facilities. 

Experimental  injections  before  human  injections. 

Before  injecting  a  hernia  the  operator  should 
be  thoroughly  acqainted  with  the  manner  of 
diffusion  of  paraffin  in  the  tissues.  This  experi- 
ence can  be  gained  by  the  making  of  numerous 
injections  into  the  carcass  of  a  small  animal 
and  the  subsequent  careful  dissection  of  the 
animal.  A  dead  cat,  dog,  rabbit,  or  chicken 
may  be  used  for  experimental  injections  and 
many  such  injections  should  be  made. 

Hyperinjection  of  a  hernial  canal  should  be 
religiously  avoided. 

Should  the  operation  fail  and  the  patient 
suffer  from  the  presence  of  the  paraffin  it  can 
be  removed  by  surgical  means  and  at  the  same 
time  the  open  operation  performed. 

The  presence  of  the  paraffin  will  not  interfere 
with  the  successful  performance  of  the  open 
operation  nor  will  it  complicate  the  operation 
so  that  the  chances  of  a  radical  cure  are  not 


diminished  from  this  method,  nor  is  the  patient 
liable  to  a  slower  convalescence. 

Vehement  protests  against  the  use  of  paraffin 
injections  are  to  be  expected  from  surgeons 
doing  the  open  operation,  and  unbiased  readers 
should  not  be  misled  by  condemnatory  remarks 
from  inexperienced  sources. 


PREPARATION  OF  THE  SKIN. 

The  hair  over  the  pubes  and  the  groin  of  the 
affected  side  should  be  cut  rather  close  and 
then  the  parts  scrubbed  with  a  solution  of  green 
soap.  A  small  amount  of  a  forty  per  cent,  solu- 
tion of  formaldehyde  may  be  added  to  the  soap 
solution  as  this  agent  is  a  very  powerful  anti- 
septic. 

Soap  solution. 

Formaldehyde  solution,  one  dram  (40%). 

Green  soap,  four  ounces. 

Dilute  alcohol  to  make  one  pint. 

The  dilute  alcohol  is  made  up  of  equal  parts 
of  ninety-five  per  cent  alcohol  and  water. 

After  the  parts  are  thoroughly  scrubbed  with 

this  solution  the  soap  should  be  removed  with 

moist  compresses  and  then  the  parts  mopped 

with   a   solution   of  seventy   per   cent   alcohol. 

Finally  the  field  of  operation  should  be  flooded 

10 


with  ether  as  this  agent  is  an  effective  antiseptic 
and  also  acts  as  a  solvent  for  any  greasy  matter 
not  removed  by  the  soap. 


11 


PREPARATION  OF  THE   HANDS  OF  THE 
OPERATOR. 

Antiseptics  cannot  be  as  freely  used  upon 
the  hands  of  the  operator  as  upon  the  skin  of 
the  patient  as  the  repeated  application  of  the 
stronger  antiseptics  cause  a  scaling  of  the 
epithelial  cells  and  finally  the  development  of 
an  irritated  state  which  prevents  cleansing  of 
the  hands  sufficiently  to  permit  operating. 

It  is  well  to  scrub  the  hands  with  the  soap 
solution  and  then  to  follow  with  the  use  of  the 
seventy  per  cent  alcohol.  The  alcohol  solution 
is  the  least  irritating  of  effective  antiseptics 
and  it  is  the  solution  in  which  needles  and 
leather  washers  should  be  kept,  so  that  they 
are  at  all  times  readv  for  use. 


12 


THE    SYRINGE. 

The  sterilized  paraffin  syringe  should  not  be 
handled  until  the  hands  have  been  scrubbed. 
The  washers  and  needles,  just  before  using, 
should  be  removed  from  the  alcohol  solution. 
It  is  unnecessary  to  wash  the  alcohol  from  the 
fingers,  washers  or  needles,  in  fact,  it  is  prefer- 
able to  leave  it  upon  them. 

Using  an  extra  large  syringe  it  is  possible  to 
operate  upon  several  patients  without  re- 
sterilizing  the  syringe.  This  instrument  may 
be  soaked  in  the  alcohol  solution,  the  needle 
changed  and  the  operator  may  continue  until 
the  syringe  is  empty. 

Even  though  one  have  a  syringe  capable  of 
holding  enough  for  several  operations  it  is  well 
to  have  a  second  at  hand  ready  for  use  as  the 
instruments  sometimes  break  or  spring  a  leak 
when  least  expected.  Never  use  a  syringe 
which  leaks,  as  one  cannot  tell  how  much  is 
going  into  the  tissues  and  how  much  is  escap- 
ing.   Leaks  invariably  occur  at  the  side  of  the 

13 


needle  base  or  at  the  point  of  juncture  of  the 
barrel  of  the  instrument  with  its  anterior  por- 
tion. Paraffin  in  the  solid  state  will  seldom 
if  ever  escape  along  the  side  of  the  plunger 
within  the  barrel  of  the  instrument  when  the 
all  metal  paraffin  sj^ringe  is  used  and  the  all 
metal  syringe  is  the  only  instrument  which 
should  be  used  for  paraffin  injections. 

The  screw  piston  is  preferable  to  the  sliding 
piston  under  all  circumstances  as  it  gives  the 
operator  a  better  control  over  the  injection. 
Injections  are  made  with  the  paraffin  com- 
pounds cold  so  that  considerable  pressure  must 
be  brought  to  bear  to  cause  the  harder  mixtures 
to  flow  through  a  long  needle. 


14 


PREPARATION  OF  THE  SYRINGE. 

The  plunger  should  be  removed  from  the 
syringe  and  the  instrument  in  two  parts  should 
be  thoroughly  boiled  before  filling.  It  should 
be  scrubbed  with  soap  and  water  if  dirty  or 
corroded  before  it  is  dropped  into  the  boiling 
water.  After  boiling  for  a  half  hour  the  barrel 
of  the  syringe  which  is  closed  anteriorly,  except 
for  the  needle  opening,  is  held  up  and  the 
melted  paraffin  poured  in  until  the  instrument 
is  quite  full,  then  the  plunger  is  fitted  in  and 
pressed  down  until  it  is  possible  to  assemble  the 
instrument  ready  for  use. 

Needles  should  be  boiled.  Leather  washers 
when  not  in  use  should  be  kept  in  solutions  of 
alcohol. 

Preparations  for  operation,  such  as  sterilizing 

syringe  and  needles  should  be  done  hours  before 

operation.     If  the  sterilized  loaded  syringe  is 

15 


placed  in  a  sterile  towel  it  may  be  kept  for 
days  and  then  before  use  to  insure  sterilization 
it  should  be  soaked  in  a  seventy  per  cent  solu- 
tion of  alcohol.  If  a  needle  is  attached  to  the 
syringe  when  it  is  thrown  in  the  alcohol  solution 
it  will  be  found  that  the  paraffin  in  the  syringe 
will  not  be  afi^ected  by  the  alcohol.  The  instru- 
ment may  be  used  from  the  alcohol  without 
even  drying  it. 

Before  inserting  the  needle  for  the  injection 
of  the  paraffin  start  its  flow  and  observe  that 
the  paraffin  is  escaping  from  the  needle  in  a 
perfectly  smooth  string. 

The  same  words  as  to  preparation  apply  when 
the  white  vaseline  is  used.  This  agent  should 
always  be  sterilized  by  heat  before  placing  it 
in  the  syringe  and  when  syringe  and  vaseline 
are  sterile  the  exterior  of  the  instrument  may 
be  re-sterilized  at  the  time  of  using  by  alcohol 
soaking. 

Paraffin  in  the  liquid  state  may  be  drawn  from 

a  large  container  directly  into  the  syringe  when 

the  needle  has  been  removed.    The  needle  may 

16 


then  be  screwed  in  place  and  the  instrument 
held  with  the  point  of  the  needle  directly  up- 
ward and  pressure  made  upon  the  piston  until 
all  air  escapes  and  the  liquid  paraffin  begins  to 
flow.  Then  the  instrument  may  be  allowed  to 
cool  and  its  contents  to  consolidate. 

Material  injected  at  room  temperature. 

All  these  injections  are  made  with  the  ma- 
terial in  the  syringe  at  room  temperature.  The 
syringe  may  be  left  filled  for  days  and  not 
heated  at  all  when  the  injections  are  finally 
made.  In  mid-winter  if  the  syringe  has  been 
kept  in  a  cold  room  its  temperature  may  be  so 
low  that  it  may  be  advisable  to  warm  it  some- 
what, but  at  an  average  temperature  of  seventy 
degrees  Fahrenheit  the  mixture  first  described 
should  flow  freely  through  an  ordinary  hypo- 
dermic needle. 


17 


PREPARATION  OF  THE  PARAFFIN. 

Some  operators  have  said  a  good  deal  about 
the  paraffin  and  the  proper  place  to  secure  it. 
As  nearly  as  can  be  learned  the  compounds  used 
in  this  country  are  products  of  the  Standard 
Oil  Company.  The  paraffin  used  in  the  formulae 
of  this  book  has  an  average  melting  point  of 
130. 

For  reducing  the  melting  point  of  the  paraffin 
mix  the  paraffin  with  the  white  vaseline  of  the 
Chesborough  company.  If  an  agent  is  sold  in 
a  tin  stamped  white  vaseline  it  should  have 
the  name  on  the  tin  of  the  Chesborough  com- 
pany as  this  is  the  only  firm  having  the  right 
to  use  this  name.  Petrolatum  albi  or  white 
patrolatum  is  a  few  cents  cheaper  than  the 
vaseline   but  the   difference  is   of  so   small   an 

amount   that   it   is   better   to   use   the   vaseline 

18 


rather   than   packages^  which   may  vary   more 
than  the  Chesborough  product. 

FORMULA  NUMBER  ONE. 

White  A'aseline.  one-half  pound. 

Paraffin,  one-half  i>ound. 

Melt  together. 

This  should  be  sterilized  by  having  the  mix- 
ture stand  in  a  coA^ered  container  in  a  vessel 
of  Avater  AAdiich  is  also  coA'ered  and  the  Avater 
should  be  kept  boiling  for  a  half  hour. 

Containers  for  sterilized  compounds. 

With  the  paraffin  may  be  boiled  a  number  of 

test  tubes.     These  after  boiling  one-half  hour 

may   be    lifted    from   the    boiling   Avater    Avith 

forceps.     As  they  Avill  be  quite  hot  if  they  are 

held   Avith   opening   doAAmAvard   the   Avater   AA^ill 

drain    from    them    and    their    OAvn    heat    Avill 

evaporate  the   feAv   drops   in  the   interior   and 

they   Avill   be   left    dry.      Into    each   test   tube 

sufficient  paraffin  may  be  poured  to  fill  a  syringe 

and  then  they  should  be  plugged  Avith  sterile 

cotton  or  corks  AA'hich  have  been  boiled.     The 

19 


test  tubes  containing  the  paraffin  mixture  may 
then  be  put  away  and  when  taken  out  at  a 
later  time  for  filling  the  syringe  the  paraffin 
may  be  melted  by  heat  and  poured  into  the 
sterile  syringe  or  the  paraffin  may  be  boiled 
'^y  holding  the  test  tube  over  a  Bunsen  burner, 
or  other  heater.  When  paraffin  boils  the  tem- 
perature of  the  boiling  mixture  is  higher  than 
that  of  boiling  water  but  the  boiling  causes 
dense  black  smoke  to  be  given  off  and  this  is 
objectionable  in  a  closed  room.  Repeated  boil- 
ing, of  paraffin  causes  it  to  discolor  but  this  does 
not  occur  when  the  vessel  containing  the 
paraffin  is  placed  in  a  water  bath  and  the  water 
around  the  paraffin  container  boiled.  No  smok- 
ing of  the  paraffin  occurs  when  it  is  heated  in  a 
water  bath  and  this  means  of  sterilization  is 
the  most  satisfactory  though  the  first  time  the 
paraffin  is  sterilized  it  should  be  kept  in  the 
boiling  water  for  a  half  hour. 

A  softer  mixture  of  paraffin,  which  may  be 
used  when  in  fear  of  the  effects  of  the  injection 
of  the  harder  mixture,  is  made  as  follows : 

20 


FORMULA  NUMBER  TWO. 

Paraffin,  two  ounces. 

White  vaseline,  eight  ounces. 

Melt  together  and  sterilize. 

This  second  paraffin  compound  is  advisable 
when  the  operator  is  anxious  to  secure  a  plug- 
ging action  with  a  mixture  which  will  always 
be  fairly  soft,  and  which  is  less  likely  to  be 
absorbed  than  plain  sterilized  white  vaseline. 

Vaseline. 

The  third  compound  is  the  sterilized  white 
vaseline.  It  is  probable  that  this  agent  is 
frequently  absorbed  in  a  comparatively 
short  time  but  it  has  the  valuable  property  of 
diffusing  freely  through  the  tissues  so  that  it 
produces  a  more  extensive  reaction  and  when 
it  is  used  in  connection  with  the  harder  mix- 
tures the  operator  may  be  more  certain  of 
securing  an  occlusive  inflammation  of  the  sac 
of  the  hernia  and  the  more  extensive  production 

of  connective  tissues  so  that  the  par+s  separated 

21 


to  make  way  for  the  passage  of  the  hernial  sac 
are  more  certainly  bound  together. 

None  of  these  mixtures  are  hard.  If  a  por- 
tion of  the  mixture  first  described  is  secured 
under  the  arm  for  a  half  hour  or  held  in  the 
mouth  for  that  length  of  time  and  it  is  raised 
to  body  temperature  it  will  be  found  that  it  is 
comparativelj^  soft.  It  is  not  a  liquid  and  it  is 
not  likely  to  be  absorbed,  yet  it  is  not  a  hard 
waxy  mass. 

The  great  danger  of  the  untrained  operator 
is  to  inject  too  much  at  one  point  and  should 
the  operator  do  this  and  get  it  in  the  canal  it 
will  make  a  lump  at  one  point  and  press  un- 
necessarily upon  the  tissues  and  in  time  will  be 
displaced  and  will  drag  involved  tissues  with  it, 
producing  discomfort  by  the  distortion. 


22 


POSTURE   OF  PATIENT  FOR  INJECTION. 

The  patient  for  injection  should  be  placed 
upon  the  back.  When  the  thigh  is  slightly 
flexed  the  wall  of  the  abdomen  is  relaxed  and 
should  the  external  ring  be  not  dilated  by  the 
protrusion  of  a  large  hernia  the  relaxation  ob- 
tained by  the  flexing  of  the  thigh  and  allowing 
the  flexed  leg  to  rest  against  the  other  will 
relax  and  dilate  the  external  ring  somewhat  so 
that  it  may  facilitate  the  free  passage  of  the 
needle  and  it  will  also  permit  of  the  more  free 
moving  of  the  point  of  the  needle  in  the  loose 
cellular  tissues  as  the  needle  is  graduall}^  with- 
drawn. 

Pelvis  high  and  head  low. 

If  the  head  is  dropped  low  and  the  pelvis  is 
high,  a  position  easily  possible  with  some  surgi- 
cal chairs,  the  veins  of  the  cord  are  depleted 

and  the   likelihood   of   opening   o^'   entering   a 

23 


vein  is  diminished.  This  posture  should  only 
be  used  where  there  is  a  well  marked  varicocele 
and  the  suction  method  of  inserting  the  needle 
should  always  be  used.  When  the  veins  are 
dilated  the  elevation  and  their  depletion  may 
prevent  the  operator  making  several  efforts  to 
pass  the  needle  without  striking  them,  a  thing 
which  is  easily  possible  in  the  presence  of  a 
canal  full  of  dilated  vessels. 

Should  there  be  a  well  marked  varicocele 
the  blunted  needle  should  be  used  so  that  it 
will  not  be  possible  to  cut  a  vein  by  the  moving 
of  the  needle  and  at  the  same  time  the  operator 
should  move  the  point  of  the  needle  slowly  from 
side  to  side  as  it  is  withdrawn. 


24 


SKIN  INFILTRATION  TO  PERMIT  OF  IN- 
SERTION OF  LONG  NEEDLE  WITH- 
OUT UNDUE  PAIN. 

It  may  be  well  to  infiltrate  the  skin  slightly 
at  the  site  of  the  puncturing  of  the  skin  with 
the  larger  needle.  To  do  this  a  weak  cocain 
or  alypin  solution  should  be  used.  This  solution 
is  made  by  the  addition  of  the  cocain  or  alypin 
tablets  to  one  or  two  drams  of  boiled  water. 

A  tablet  containing  six  tenths  of  a  grain  of 
alypin  or  cocain  is  sufficient  for  a  dram  solution. 
A  few  drops  of  this  injected  over  the  external 
ring  will  permit  of  the  passage  of  the  needle 
through  the  tough  skin  without  pain.  The 
pressing  of  the  needle  along  the  roof  of  the 
canal  is  not  usually  sufficiently  painful  to  call 
for  much  complaint  from  the  patient. 

If  the  patients  are  nervous  a  preliminary  in- 
jection of  a  one  per  cent  solution  of  cocain  or 


alypin  into  the  inguinal  canal  is  not  contra- 
indicated.  To  accomplish  this  the  larger  needle 
should  be  screwed  upon  the  infiltrating  syringe 
and  as  the  needle  is  pressed  into  the  canal  the 
solution  is  slowly  forced  in  front  of  the  needle 
point.  If  sufficient  solution  is  thrown  ahead  of 
the  needle  the  passage  of  the  needle  along  the 
inguinal  canal  is  entirely  painless. 

The  infiltration  of  skin  or  canal  being  com- 
plete the  needle  must  be  withdrawn  and  the 
syringe  emptied  and  the  plunger  pressed  down 
so  that  the  empty  syringe  is  attached  to  the 
needle  through  which  the  paraffin  injection  is 
to  be  made  when  the  operator  has  assured  him- 
self that  the  needle  has  been  passed  as  far  as 
desired  without  traversing"  or  puncturing  a 
vein. 


26 


THE  EFFECT  OF  PARAFFIN  COMPOUNDS 

UPON  THE  TISSUES. 

No  matter  what  precautions  are  taken, 
paraffin  deposited  in  the  tissues  causes  an  in- 
creased flow  of  blood  to  the  parts.  The  re- 
action is  in  the  nature  of  a  distinct  active 
hyperemic  state  and  it  is  sufficient  to  cause  the 
proliferation  of  connective  tissue.  Even  if  pure 
white  vaseline  alone  is  injected  there  will  be 
'  such  connective  tissue  proliferation  and  if  the 
paraffin  is  deposited  close  along  the  peritoneal 
surfaces  of  the  sac  sufficient  of  a  circulatory 
disturbance  will  be  produced  to  result  in  the 
sticking  together  of  the  serous  surfaces  of  the 
sac  and  such  sticking  together  of  the  walls  will 
mean  an  elimination  of  the  patency  of  the  sac, 
one  of  the  essential  features  of  a  radical  cure. 
The  paraffin  compound  number  one  is  of  such 

consistency  that  it  is  unlikely  to  be  absorbed 

27 


and  properly  placed  with  discretion  it  will 
favor  the  retention  of  the  hernia  by  acting  as 
a  plug.  This  plugging  action  is  not  likely  to 
be  successful  if  the  paraffin  is  simply  thrown  in 
as  a  mass,  as  it  will  be  displaced,  and  Avhen 
displaced  it  will  make  undue  traction  upon 
parts  with  which  it  is  intimately  connected  so 
that  should  the  paraffin  be  thrown  in  in  the 
form  of  an  irregular  mass  closing  only  a  small 
part  of  the  canal  and  such  displacement  occur 
the  patient  may  suffer  considerable  discomfort. 

The  corking  action  of  the  paraffin  is  not  to 
be  disregarded,  yet  at  the  same  time  it  must 
be  remembered  that  the  injection  must  be  so 
diffused  that  the  supporting  mass  has  Cjuite  a 
luiiversal  support  from  all  the  tissues  from 
the  internal  ring  clear  out  to  the  external  ring. 

It  must  also  be  rememberedjhat  the  paraffin 
thrown  into  the  tissues  causes  a  thickening  of 
the  tissues  and  should  the  canal  be  filled  with 
paraffin  with  the  thickening  which  so  rapidly 
develops  the  canal  will  be  unduly  crowded. 

If  the  canal  is  plugged  up  tightly  and  marked 


pressure  is  made  iipon  the  nerves  of  the  cord 
at  one  point  it  is  likely  that  discomfort  will 
be  produced  which  will  last  for  some  time. 

Object  of  operator. 

The  object  of  the  operator  is  to  secure  a 
diffusion  of  the  injection  through  the  loose 
cellular  tissues  bj^  the  directing  of  the  needle 
in  all  directions  as  it  is  Avithdrawn.  This 
diffusion  is  facilitated  by  the  nature  of  the 
paraffin.  It  is  not  to  be  forgotten  that  the 
vaseline  diffuses  very  readily  and  extensively 
and  if  the  operator  is  fearful  of  overinjecting 
the  parts  it  is  best  to  use  it  in  excess  rather 
than  the  harder  mixture. 

If  the  needle  is  simply  withdrawn  the  paraffin 
is  not  thrown  into  the  canal  in  a  regular  pencil- 
like plug  but  it  lumps  irregularly  with  small 
diverticula  projecting  from  each  irregular 
mass. 

The  free  moving  of  the  needle  point  in  all 
directions  as  the  needle  is  withdrawn  favors 
the  diffusion  and  avoids  the  unsatisfactory 
lumping  of  the  injection. 

29 


THE    IMMEDIATE    AFTER    EFFECTS    OF 

THE  PARAFFIN  INJECTIONS. 

Within  twelve  hours  after  the  operation  the 
tissues  are  ahnost  certain  to  become  quite  sen- 
sitive to  pressure.  The  reaction  may  be  fol- 
lowed by  considerable  pressure  pain  for  a  day 
or  two.  Should  the  patient  not  be  comfortable 
while  at  rest,  that  is  sitting  about  or  lying 
down;  then  something  should  be  given  to  re- 
lieve the  pain.  Codeine  is  the  most  satisfactory 
agent  for  preventing  the  patient  from  feeling 
pain  during  the  most  acute  stage  of  the  reaction. 
Codeine  does  not  put  the  patient  to  sleep  as 
does  morphine,  nor  does  codeine  constipate  or 
make  the  skin  itch.  Codeine  is  only  about  one- 
third  or  one-fourth  as  toxic  as  morphine  and 
consequently  it  may  be  given  in  a  proportion- 
ately larger  dose.     It  may  be  given  in  tablet 

form  or  in  solution  by  the  mouth.     The  best 

30 


way  to  administer  it  is  in  doses  of  one-half 
grain  every  hour  while  the  patient  is  suffering 
actual  pain.  Tell  the  patient  that  it  will  relieve 
him  of  unpleasant  symptoms  during  the  reac- 
tion and  that  it  is  undesirable  that  he  should 
suffer  from  the  reaction.  In  this  way  the 
patient  will  be  kept  quite  comfortable  during 
the  time  that  the  reaction  is  sufficient  to  cause 
pain.  It  is  impossible  to  tell  whether  the  re- 
action will  be  such  as  to  cause  any  pain  or  not. 
In  case  it  does  not  develop  no  internal  treat- 
ment is  necessary.  Other  agents  may  be  used 
to  relieve  pain,  though  none  offer  the  advant- 
ages of  codeine  without  disadvantages.  It  is 
not  advisable  to  let  these  patients  suffer  from 

a  severe  reaction.  It  is  better  to  meet  the  first 
indications  of  pain  with  the  free  administration 
of  codeine.  The  patient  should  not  know  the 
nature  of  the  drug,  and  as  it  produces  none  of 
the  peculiar  effects  of  morphine  it  is  not  really 
a  drug  at  all  dangerous  from  the  habit  forming 
standpoint. 

Local  applications   of  heat   or   cold  may  be 
used  if  the  reaction  is  well  marked 

31 


THE    PRACAUTION    USED    TO    PREVENT 

THROWING    OF    PARAFFIN   INTO 

THE  CIRCULATION. 

In  all  cases  precautions  shonld  be  taken  to 
avoid  throAving  of  the  paraffin  mixture  directly 
into  the  circulation.  This  is  accomplished  by 
passing  the  needle  slowly  into  the  tissues  which 
are  to  be  injected  and  while  the  needle  is  pass- 
ing through  the  tissues  it  should  have  a  strong 
vacuum  suction  upon  it  so  that  should  it  strike 
a  vein  the  blood  will  immediately  begin  to  flow 
into  the  needle.  To  illustrate  how  easily  blood 
may  be  sucked  from  a  vein  a  hypodermic  with 
a  glass  barrel  may  be  taken  armed  with  a  small 
needle.  If  the  arm  of  a  patient  be  allowed  to 
hang  down  the  veins  will  distend  and  the  point 
of  the  needle  may  be  slipped  through  the  skin 
and  into  the  vein.    If  the  vein  is  punctured  by 

the  needle  point  the  instant  the  piston  of  the 

32 


syringe    is    drawix   back    a    vacuum    forms    in 

the  syringe  and  the  blood  will  flow  into  the 

syringe.     This  same  method  is  to  be  used  in 

the  passage  of  the  larger  paraffin  needle  or  any 

paraffin   needle   only   as   the   needle   is   passed 

along  its  course  the  suction  should  be  constantly 

exerted.     This  constant  suction  is  secured  by 

simply  attaching  the  half  glass  syringe  to  the 

needle   and  then  as  soon  as  the  point  of  the 

needle  is  under  the  skin  the  piston  is  withdrawn 

and  a  vacuum  formed.    Then  holding  the  piston 

of  the  syringe  out,  maintaining  the  vacuum,  the 

needle  is  pushed  slowly  in  as  far  as  the  operator 

desires  to  inject.     Should  blood  begin  to  flow 

into  the  needle  at  any  point  the  onward  passage 

of  the  needle  is  stopped  and  is  withdrawn  and 

re-inserted  in  a  somewhat  different  direction, 

particularly  if  during  the  withdrawal  a  point 

is  found  where  the  blood  flows  steadily  into 

the  syringe. 

If  at  no  point  blood  flows  into  the  syringe  it 

is  plain  that  no  vessel  of  dangerous  size  has 

been  punctured  by  the  needle.     The  veins  of 

33 


the  cord  are  found  rather  closely  around  the 
cord  and  the  cord  usually  lies  below  and  behind 
the  sac  so  that  should  the  operator  aim  to  carry 
his  needle  point  along  rather  high  in  the  canal 
he  will  be  least  likely  to  encounter  these  vessels. 
It  is  not  to  be  forgotten  that  the  veins  of  the 
cord  are  particularly  likely  to  be  somewhat 
dilated  in  these  cases  of  hernia  and  the  operator 
is  taking  more  or  less  of  a  hazard  in  neglecting 
the  suction  technic  outlined.  It  is  not  safe  to 
trust  to  the  fact  that  the  paraffin  is  injected  in 
a  solid  state  as  is  asserted  by  some  operators. 
It  is  true  that  paraffin  in  a  liquid  state  is  more 
likely  to  flow  into  an  opened  vein  than  the 
paraffin  in  the  solid  state,  yet  it  is  possible  to 
throw  a  very  small  amount  of  solid  paraffin 
into  a  vein  if  no  precaution  is  taken  to  prevent 
it.  and  while  a  very  small  mass  thrown  directly 
into  a  vein  would  be  harmless  in  nearly  all  in- 
stances it  might  do  considerable  damage  should 
it  be  so  unfortunate  as  to  lodge  in  certain 
vessels. 


34 


FACTORS  TO  BE  CONSIDERED  IN  DEAL- 

ING  WITH  INGUINAL  HERNIA. 

The  inguinal  canal  gives  passage  to  the  sper- 
matic cord.  It  is  an  oblique  canal  extending 
from  a  point  one-half  an  inch  above  the  center 
of  Poupart's  ligament  to  the  spine  of  the  pubes. 
The  cord  emerging  from  the  external  ring  con- 
tinues into  the  scrotum,  and  the  most  definite 
manner  of  finding  the  external  ring  is  by  pick- 
ing up  the  cord  in  the  scrotum  and  following 
it  with  the  index  finger  until  the  point  of  the 
index  finger  is  pressed  into  the  canal,  the 
scrotum  being  invaginated  at  the  same  time. 
In  scrotal  hernia  when  the  patient  is  placed  in 
the  recumbent  posture  the  contents  of  the  her- 
nial sac  may  be  pressed  into  the  abdomen  and 
the  finger  following  the  receding  hernial  con- 
tents will  slip  into  the  opening  of  the  external 

ring. 

35 


OPERATOR  MUST  BE  SURE  HERNIA 
IS  REDUCED. 

A  hernia  should  always  be  completely  re- 
duced before  any  operation  is  attempted  and 
the  size  and  situation  of  the  external  ring 
definitely  determined.  The  larger  and  the  longer 
a  hernia  has  been  allowed  to  go  unreduced  the 
shorter  the  inguinal  canal  will  be,  as  the  inner 
margin  of  the  internal  ring  is  gradually  forced 
toward  the  median  line  of  the  body,  and  in 
very  large  hernia  the  external  ring  is  stretched 
somewhat  outward  so  that  an  opening  exists 
directly  through  the  abdominal  wall.  Thia 
character  of  hernia  is  such  that  three  fingers 
may  easily  be  pressed  directly  into  the  hernial 
interval  and  as  a  rule  so  much  of  the  abdominal 
contents  have  been  outside  the  abdomen  for  so 
long  that  the  hernia  cannot  be  overcome  with- 
out decidedly  increasing  abdominal  pressure. 
These  cases  in  which  hernial  contents  can  be 
pressed  into  the  abdomen  by  force  and  which 

markedly  increase  the  intra-abdominal  pressure 

36 


when  reduced  are.unsuited  for  any  operative 
treatment  which  does  not  include  excision  of  a 
quantity  of  omentum. 

The  average  case. 

In  the  average  case  the  examination  of  the 
external  ring  will  not  show  a  canal  so  greatly 
dilated  and  it  may  be  taken  for  granted  that 
it  has  not  been  shortened  to  a  considerable  ex- 
tent by  the  giving  of  the  internal  margin  of 
the  internal  ring  toward  the  median  line.  Un- 
der these  circumstances  the  operator  may  de- 
cide that  he  has  a  canal  of  from  two  to  three 
inches  in  length  and  lying  parallel  to  Poupart's 
ligament  and  slightly  above  this  structure. 

The  sac  of  the  hernia  usually  lies  above  and 
in  front  of  the  cord. 

Running  closely  connected  with  the  cord  are 

the  veins  which  go  to  make  up  the  pampiniform 

plexus.     These  veins  being   close  to   the   cord 

and  the  cord  itself  quite  susceptible  to  pressure 

it  is  advisable  to  pass  the  needle  along  near  the 

roof  of  the  inguinal  canal  and  to  attain  this 

37 


end  it  is  well  to  locate  definitely  the  external 
ring  and  to  have  a  distinct  knowledge  of  the 
exact  situation  of  the  upper  margin  of  the  ring. 

Considerable  cellular  tissue  is  found  in  the 
inguinal  canal  so  that  in  passing  the  needle 
through  the  canal  should  it  meet  with  consider- 
able resistance  it  has  no  doubt  missed  the  canal 
and  entered  some  of  the  more  resistant  tissues 
making  up  its  walls. 

The  cellular  tissue  in  the  canal  is  to  receive 
the  injection  of  the  operator  and  it  will  be  his 
object  to  facilitate  the  diffusion  of  the  various 
materials  injected  so  that  an  extensive  forma- 
tion of  connective  tissue  will  be  promoted.  The 
plug  action  of  the  injection  is  not  alone  to  be 
considered  for  the  operator  is  then  likely  to 
throw  too  much  into  the  canal  and  with  the 
development  of  the  connective  tissue  the  canal 
is  unduly  crowded. 

The  ill  consequences  of  hyperinjection  should 
not  be  forgotten.  It  is  the  error  to  which  the 
beginner  is  most  liable. 

38 


WHERE  THE  INJECTION  SHOULD 
BE  PLACED. 

Some  operators  have  been  content  to  insert 
a  needle  over  the  approximate  site  of  the  in- 
ternal ring  and  then  to  force  it  downward  until 
it  lies  as  close  to  the  internal  ring  as  they  can 
approximate  and  then  to  throw  in  a  mass  of 
paraffin  sufficient  to  occlude  the  canal  at  this 
point. 

If  the  needle  is  inserted  about  half  an  inch 
above  the  middle  of  Poupart's  ligament  it  will 
be  over  the  site  of  the  normal  internal  ring. 
After  the  needle  passes  through  the  subcutane- 
ous fat  it  will  be  felt  to  strike  the  firm  fibrinous 
layers  of  the  external  wall  of  the  inguinal  canal. 
After  the  needle  has  passed  through  this  firm 
layer  it  will  enter  the  loose  cellular  tissue  in 
the  neighborhood  of  the  internal  ring.     If  the 

injection  is  diffused  over  an  area  o-F  an  inch  or 

39 


an  inch  and  a  half  in  circumference  the  internal 
ring  is  likely  to  be  plugged  for  the  time  bj^  tliQ 
injection. 

The  larger  Hernia. 

Should  the  hernia  be  large  the  injection 
should  be  made  closer  to  the  pubes,  but  injec- 
tion at  the  internal  ring  is  not  sufficient,  the 
canal  should  also  be  injected  with  a  certain 
amount  of  the  paraffin  and  vaseline. 

The  canal  may  be  injected  by  passing  the 
needle  directly  through  the  outer  wall  of  the 
inguinal  canal,  remembering  its  course  about 
one-half  inch  above  the  line  of  Poupart's  liga- 
ment. 

The  most  satisfactory  plan  of  injecting  where 

the  operator  can  successfully  follow  the  technic 

is  to  find  the  external  ring  and  then  insert  the 

needle  directly  into  the  external  ring  close  to 

its  upper  margin  and  to  carry  the  needle  along 

for  at  least  two  inches.     The  suction  technic 

should  be  followed  and  the  needle  should  be 

40 


moved  in  all  directions  as  it  is  withdrawn  and 
the  deposit  diffused  as  much  as  possible. 

About  the  external  ring  itself  and  directly 
between  the  pillars  of  the  external  ring  a  cer- 
tain amount  of  the  injection  should  be  placed. 


41 


THE  AMOUNT  OF  PARAFFIN  TO  BE  IN- 
TRODUCED IN  A  GIVEN  CASE. 

The  tendency  is  to  overinject  a  case.  One 
must  not  forget  that  the  tissues  will  probably 
thicken  to  twice  the  size  of  the  mass  injected. 
The  operator  must  estimate  as  nearly  as  possible 
the  size  of  the  tract  to  be  filled  and  then  aim  to 
throw  in  enough  to  about  half  fill  it.  The 
diffusion  of  the  paraf&n  will  usually  safely  hold 
the  hernia  when  the  patient  rises  from  the 
table. 

Should  the  operator  throw  in  mixtures  one 
and  two  until  the  parts  are  fairly  distended  and 
the  hernia  be  not  held  it  is  better  to  use  only 
the  plain  sterile  vaseline  for  a  subsequent  in- 
jection at  the  site  of  the  internal  ring.  If  a 
half  dram  of  vaseline   at  this  point  does  not 

hold  the  hernia  a  small  amount  of  vaseline  may 

42 


then  be  thrown /in  the  central  portion  of  the 
canal. 

At  first  the  vaseline  injections  should  be  nsecl 
whenever  in  doubt  as  to  the  amount  needed 
above  a  certain  point.  As  the  operator  becomes 
acquainted  with  the  needs  of  cases  by  experi- 
ence the  vaseline  can  be  largely  substituted  by 
the  paraffin  mixture  number  one. 


43 


TECHNIC  TO  BE  USED  IN  INJECTING 
INGUINAL  HERNIA. 

Have  a  syringe  loaded  with  paraffin  mixture 
nnmber  one  and  another  loaded  with  sterile 
vaseline.  See  that  the  paraffin  flows  smoothly 
from  the  syringe  without  leaks.  See  also  that 
the  vaseline  syringe  is  working  smoothly. 

Have  needles  intended  for  injection  of  par- 
affin free  from  this  agent.  Place  patient  on 
back,  thighs  flexed  slightly  or  straight  if  the 
external  ring  is  easily  accessible.  Follow  the 
spermatic  cord  and  locate  definitely  the  ex- 
ternal ring. 

Attach  empty  syringe  to  needle.    Pass  needle 

point  through  skin.    As  soon  as  needle  point  is 

through  skin  exhaust  syringe.     That  :s   draw 

piston    out   to    form   vacuum    in    syringe    and 

obtain  suction.    Pass  the  needle  slowly  through 

44 


external  ring  and  along  close  to  the  ro^f  of 
inguinal  canal. 

When  needle  is  in  full  length,  if  no  vein  has 
been  struck  and  blood  aspirated  into  the 
syringe,  detach  syringe  and  screw  the  paraffin 
syringe  tightly  to  needle. 

Inject  a  few  drops  of  paraffin  by  screwing 
down  syringe.  As  paraffin  is  flowing  move  tlie 
point  of  the  needle  about  in  the  loose  cellular 
tissue  and  continuing  the  injection  slowly  with- 
draw the  needle.  Continue  moving  the  point 
of  the  needle  in  all  directions  as  the  needle  is 
withdrawn  so  that  the  paraffin  will  be  diffused 
as  much  as  possible.  As  the  point  of  the  n(  (  die 
emerges  between  the  pillars  of  the  external  ring 
discontinue  the  injection. 

Test  the  effectiveness  of  the  injection. 

Allow  patient  to  stand  on  feet.  If  the  hernia 
reappears  have  the  patient  lie  down  again  and 
reinsert  the  needle  as  before  described  and  in- 
ject  sterile   vaseline   rather   than   the   paraffin 

mixture. 

45 


Xot  more  than  enough  paraffin  to  half  fill 
the  canal  should  be  injected.  If  such  quantity 
does  not  hold  hernia  sterile  vaseline  should  be 
used  discreetly  until  hernia  is  held. 

The  surgeon  must  estimate  the  approximate 
size  of  the  inguinal  canal  by  the  size  of  the 
external  ring. 

If  a  vein  is  struck  the  needle  should  be  with- 
drawn and  the  syringe  emptied  of  blood;  then 
the  needle  should  be  reinserted,  using  the 
syringe  for  suction.  If  a  vein  is  struck  a  second 
time  it  will  be  well  to  insert  the  needle  through 
the  abdominal  wall  at  the  site  of  the  internal 
ring  and  if  no  vein  is  struck  at  this  point  an 
injection  may  be  made.  If  this  holds  the  hernia 
it  may  be  well  to  make  no  injection  of  canal 
for  two  weeks.  During  the  interval  even  if  the 
hernia  does  not  recur  it  will  be  well  for  patient 
to  wear  web  bandage  truss  or  a  spica  bandage 
with  a  pad  pressure  over  the  inguinal  canal. 
At  the  end  of  two  weeks  inject  canal  moderate- 
ly with  paraffin  or  vaseline  to  promote  forma- 
tion of  connective  tissue. 

46 


If  the  injection' of  the  canal  at  the  site  of  the 
internal  ring  does  not  hold  the  hernia,  reduce 
the  same  and  make  a  puncture  with  a  small 
needle  through  the  external  wall  of  the  canal 
just  above  the  external  ring.  If  no  vein  is 
struck  inject  moderately  and  see  if  such  injec- 
tion holds  hernia.  In  such  a  case  place  pad  of 
moderate  size  over  the  canal  and  put  on  firm 
spica  and  have  the  patient  stay  off  of  feet  as 
much  as  possible  for  ten  days  or  two  weeks. 
In  this  case  the  permanence  of  the  cure  will 
depend  upon  the  amount  of  connective  tissue 
formed. 

Injection  at  Internal  ring. 

To  inject  through  the  abdominal  wall  at  the 
internal  ring  select  a  point  midway  between 
the  anterior  superior  spine  of  the  ilium  and 
the  pubes  and  one-half  an  inch  above  the  line 
of  Poupart's  ligament.  This  represents  the  site 
of  the  internal  ring.  The  needle  should  be 
pressed  through  the  fibrinous  wall  of  the  canal 

at  this  point  and  should  be  directed  towards 

47 


the  pubes.  If  the  hernia  is  at  all  large  remem- 
ber that  the  canal  is  shortened  and  select  a 
point  one-half  or  three-quarters  of  an  inch 
nearer  the  pubes  as  the  site  of  the  ring.  When 
through  the  outer  wall  of  the  inguinal  canal 
the  needle  point  will  have  a  considerable  free- 
dom in  the  loose  cellular  tissue  and  the  injection 
should  be  diffused  in  a  circle  of  an  inch  or  an 
inch  and  a  half  in  diameter.  Before  taking  off 
the  suction  syringe  after  the  passage  of  the 
needle  sweep  the  point  slowly  in  a  circle  to 
make  sure  that  no  vein  has  been  opened  or  is 
likely  to  be  opened  as  the  needle  is  swept  about. 

The  hypodermic  needle  for  injection. 

A  hypodermic  needle  may  be  used  for  an 
internal  ring  injection  or  an  injection  through 
the  anterior  wall  of  the  canal,  but  in  moving  it 
about  the  operator  should  watch  carefully  and 
not  break  such  needle.  If  a  needle  breaks  it 
will  be  at  the  shoulder  formed  by  the  point 
of  attachment  of  the  shaft  of  the  needle  with 

the  butt. 

48 


The  advantage  of  the  small  hypodermic 
needle  is  that  it  may  be  passed  with  very  little 
discomfort  to  the  patient  and  it  throws  a  finer 
string  of  paraffin  and  favors  diffusion  of  the 
agent. 

A  hypodermic  needle  is  lacking  in  length  to 
inject  the  canal  when  passed  through  the  ex- 
ternal ring  along  the  canal. 

Should  the  surgeon  attempt  injection  along 
the  canal  and  find  the  patient  too  nervous  or 
the  technic  too  difficult  the  hypodermic  may 
be  used  and  an  injection  made  through  the 
anterior  wall  of  the  canal  at  the  internal  ring, 
at  about  the  center  of  the  canal  and  about  one- 
half  an  inch  from  the  external  ring. 

The  hypodermic  needle  injections  are  simple 
and  should  be  accomplished  even  on  a  very 
nervous  patient  without  troubling  to  infiltrate 
with  cocain  or  alypin. 


49 


-V     cT    BE  DISCREET  IF    INJECTION   IS    PAINFUL. 

Should  a  patient  complain  that  the  injection 


c 


is  painful  inject  very  discreetly  or  better  check 
the  injection  there,  move  the  point  of  the  needle 
and  again  try  slowlj^  Tf  the  cold  injection 
causes  pain  try  at  another  point.  Put  in  a  drop 
or  two  and  should  the  patient  still  complain 
discontinue  and  put  on  a  spica  or  truss  for  a 
few  days.  Observe  the  reaction  and  then  if  it 
is  not  severe  inject  again. 

Eemember  that  several  injections  may  be 
made  upon  a  patient  but  hyperinjection,  that  is 
the  injection  of  too  much,  will  cause  no  little 
distress  and  that  it  is  impossible  to  remove  all 
the  paraffin  mixture  or  the  vaseline  v/ithout 
an  open  operation,  if  thej^  are  not  absorbed. 

Needle  punctures  should  be  sealed  with  col- 
lodion.    No  other  dressings  are  required. 

Begin  codeine  early  and  use  freely  when  a 
painful  reaction  develops. 


50 


THE   INJECTION   OF  FEMORAL  HERNIA. 

The  femoral  ring  is  below  Poupart's  liga- 
ment. When  the  femoral  hernia  protrudes 
through  the  crural  canal  it  is  directed  upward 
over  Poupart's  ligament.  To  reduce  it  pres:^ 
the  mass  toward  the  feet  of  the  patient  and  then 
upward  toward  the  abdominal  cavity.  The 
saphenous  opening  may  then  be  felt.  On  the 
outer  side  of  the  opening  is  the  large  vein  of 
the  thigh.  The  needle  should  be  inserted  at 
the  inner  extremity  of  the  opening,  that  is  to- 
ward the  median  line.  Aspirating  of  blood  may 
mean  the  puncture  of  this  large  vein  and  it  may 
not  be  advisable  to  inject  carelessly  when  this 
vein  has  been  wounded  owing  to  its  size.  The 
crural  canal  is  only  about  a  half  inch  in  length. 
The  injection  of  it  may  be  accomplished  with 
a  hypodermic  needle.     It  is  not  well  to  sweep 

the   point   of   the  needle   externally   with   too 

51 


great  freedom  as  the  vein  may  be  wounded. 
Inject  slowly  and  move  the  point  of  the  sj^nnge 
carefull.y  so  that  the  injection  may  be  diffused 
in  the  canal. 


INJECTION  OF  UMBILICAL  HERNIA. 

Reduce  the  hernia  and  examine  the  margins 
of  the  hernial  ring  with  care  so  as  to  be  thor- 
oughly acquainted  with  the  character  and  situa- 
tion of  these  margins.  Remember  that  the 
tissues  are  often  very  thin  and  that  an  injection 
in  the  center  of  the  hernia  may  simply  go 
through  the  peritoneum  and  thus  be  placed 
directly  in  the  abdomen.  Injections  of  paraffin 
into  the  peritoneal  cavity  of  animals  have  not 
proven  to  be  dangerous,  the  agent  not  causing 
irritation  of  the  surface  of  the  peritoneum 
when  sterile. 

Umbilical  hernia  may  be  injected  with  a 
hypodermic  needle  building  out  from  the  mar- 
gins of  the  hernial  opening,  but  it  is  well  not 
to  inject  with  too  great  freedom.  After  diffus- 
ing the  tissues  of  the  canal  or  ring  a  pad  and 
binder  should  be  applied  and  the  patient  given 


two  weeks  interval  to  see  if  sufficient  of  the 
connective  tissue  has  developed  to  close  the 
canal.  If  the  hernia  is  not  overcome  and  recurs 
injections  may  be  repeated. 


54 


Case  Reports 


Case  1. 

Case  1  A.  G. — ^Italian  child,  age  twenty-eight 
jnonths,  female.  (Ass.  Civ.  Char.  Disp.) 
Umbilical  hernia  protruding  about  one-half 
inch  and  with  an  opening  which  may  be  filled 
by  tip  of  index  finger. 

Parts  thoroughly  sterilized,  hernia  reduced 
and  contents  held  in  abdominal  cavity  by  pres- 
sure of  index  finger  of  assistant.  The  margins 
of  ring  and  the  skin  covering  hernial  opening 
injected  with  paraffin  of  melting  point  108. 
In  effort  to  avoid  puncturing  of  hernial  sac 
and  throwing  paraffin  into  the  pertoneal  cavity 
the  skin  of  sac  injected  with  the  paraffin.  About 
half  dram  amomit  used.  Operation  Jan.  17, 
1905.  Jan.  18,  1905.  Temp,  normal.  Parts 
sensitive.  Cries  and  struggles  when  parts 
touched.  May  13,  1905.  Last  examination. 
Skin  somewhat  red.  Paraffin  mass  easily  palp- 
able.   Skin  red  but  not  sensitive. 


69 


Case  2. 

Case  2  A.  C.  C— Disp.  W.  P.  Swedish  boy, 
age  2  years  and  9  months.  Injected  Feb.  3, 
1905.  Hernia  as  large  as  walnut.  Reduced. 
Finger  of  assistant  holding  in  contents.  Injec- 
tion made  into  tissue  surrounding  the  hernial 
opening  with  view  of"  crowding  margins  to- 
gether. Half  dram  injected.  Child  crying 
forced  contents  into  sac.  Reduced  and  injection 
under  skin  of  sac  and  around  margins  of  open- 
ing to  plug.  Nearly  dram  parai¥in  used,  melting 
point  lOS. 

Parts  moderately  sensitive  at  end  of  week. 
Xo  redness  though  paraffin  mass  palpable  close 
under  skin  and  intimately  connected  with  it. 
April  11.  1905.  Last  examination.  Xo  redness. 
no  tenderness,  no  recurrence. 


TO 


Case  3. 

Case  3  T.  F. — Teamster.  Irish  parentage. 
Age  20.  A.  C.  C.  Disp.  Bubonocele,  left  side. 
First  noted  four  weeks  previously.  Operation 
May  14.  1905.  Area  sterilized.  Small  area  of 
skin  infiltrated  with  a  one  percent  solution  of 
cocain.  Paraffin  melting  point  108,  injected 
over  area  of  prominence  of  bubonocele  and  into 
upper  portion  of  canal.  Two  pimctures  made  a 
dram  and  a  half  of  paraffin  injected.  Parts 
sensitive  for  three  days  so  that  patient  walked 
without  bending  thigh  at  hip  joint.  No  temper- 
ature. Local  applications.  Codeine  given  in 
c[uarter  grain  doses  every  two  hours.  Fourth 
day  parts  much  less  sensitive,  can  bend  leg 
freely  in  sitting  or  walking.  Area  prominent 
from  swelling  but  no  impulse.  Examination 
June  25,  1905.  No  pain,  no  tenderness,  no  im- 
pulse, prominence  in  region  of  internal  ring 
slightly  greater  than  on  opposite  side. 


Case  4. 

Case  4  A.  P. — Sicilian.  Worker  in  shoe  fac- 
tory. Age  24.  Hernia  four  months  duration. 
Never  retained  by  truss.  Sac  extends  half  way 
to  bottom  of  scrotum.  Pubes  shaved,  skin  ster- 
ilized. Operation  Aug.  26,  1905.  Skin  jin-^ 
filtrated  to  allow  passage  of  large  needle  with- 
out pain.  Injection  at  internal  ring  of  forty 
minims.  Injections  into  canal  of  about  thirty 
minims.  In  attempting  to  inject  paraffin  in  cold 
state  screw  piston  syringe  broken.  All  metal 
syringe  used  for  infiltrating,  warmed  and  filled 
with  melted  paraffin.  In  using  syringe  to  inject 
the  canal  near  the  external  ring  the  needle 
plugged.  Using  all  force  possible  the  plug 
forced  from  needle  and  over  a  dram  of  melted 
paraffin  thrown  between  the  pillars  of  the  ex- 
ternal ring.  Patient  complained  of  considerable 
pain.  Codeine  used  one-fourth  grain  every  hour. 
On  the  third  day  after  injection  skin  over  the 
external  ring  infiltrated  and  Avith  sharp  spoon 
about  a  half  dram  of  paraffin  removed.    Opera- 

72 


tion  painless.  Formaldehyde  solutions  one  to 
five  thousand  used  as  moist  dressings.  Codeine 
continued  for  two  days  longer.  Patient  lost  one 
week  from  work.  Sept.  24,  1905.  No  recurrence, 
no  pain  or  tenderness.  Area  at  former  site  of 
hernia  slightly  more  prominent  than  opposite 
side,  no  redness  of  skin. 

Case  5. 
Case  5  F.  C. — American  born,  age  18.  Private 
patient.  Hernia  about  size  of  average  marble 
midway  between  ensiform  cartilage  and  um- 
bilicus. Spontaneous  origin.  Injected  at  oiBce 
with  half  dram  of  paraffin,  melting  point  115. 
Operation  Dec.  2,  1905.  About  half  dram  total 
quantity  used.  No  reaction  when  adhesive  strip 
removed  on  fourth  day.  Slightly  tender  on 
pressure.  Examination  Feb.  7,  1906.  No  recur- 
rence, no  redness,  no  pain. 


73 


Case  6. 

Case  6  J.  C. — Italian  barber.  A.  C.  C.  Disp. 
Inguinal  hernia  on  right  side.  Noted  three 
weeks  before.  Sac  protruding  through  external 
ring.  Injection  after  infiltration.  Forty  minims 
injected  about  internal  ring.  Twenty  minims 
in  canal.  Twelve  or  fifteen  minims  thrown  be- 
tween the  pillars  of  external  ring.  Codeine 
prescribed  but  not  taken.  Parts  quite  sensitive 
on  third  day.  Xo  fever.  Sleeps  well  with  two 
pillows  under  thigh  of  affected  side.  Fifth  day, 
no  pain,  tenderness  very  much  less,  able  to  bend 
leg  almost  as  freely  as  ever.  Twelfth  day  im- 
pulse at  internal  ring?  (Questionable.)  Injec- 
tion of  twenty  minims  at  internal  ring,  ten  into 
canal  and  ten  between  pillars,  melting  point 
104.  March  4,  1906.  Last  examination.  No 
recurrence,  no  pain  or  tenderness. 


74 


Case  7. 

Case  7  A.  Y. — Femoral  hernia.  Female,  age 
35,  A.  C.  C.  Disp.  "Worker  in  tailor  shop.  His- 
tory of  case  indefinite  as  to  length  of  time  pres- 
ent. Never  been  treated  in  any  way.  Operation 
March  21,  1906.  Injection  of  forty  minims  of 
paraffin  through  saphenous  opening  and  about 
ten  minims  through  Poupart's  ligament.  Code- 
ine discontinued  at  end  of  fourth  night.  Ten- 
derness slight.  No  recurrence  at  end  of  twenty 
days.    Patient  not  seen  subsequently. 


Case  8. 

Case  8  E.  H. — Marshalltown,  Iowa.  Private 
patient.  American  born.  Varicocele  on  left 
side  and  oblique  inguinal  hernia.  Operation 
April  16,  1906.  Infiltration  and  removal  of 
dilated  veins  in  scrotum.  Wound  closed  and 
inguinal  canal  followed  by  large  needle.  No 
blood  aspirated  and  cold  paraffin  mixture  with 
melting  point  115  injected  along  canal.  About 
forty  minims  thrown  along  canal  and  then  punc- 
ture made  at  site  of  internal  ring  and  half  dram 
cliffused  at  this  point. 

Personal  communication  one  year  later  mak- 
ing final  payment  for  operation.  Patient  cured 
and  grateful. 


76 


Case  9. 

Case  9 — Italian  section  worker  wearing 
spring  truss  for  holding  of  inguinal  hernia. 
Strong  pressure  of  truss  making  marked  depres- 
sion at  site  of  internal  ring.  Patient  injected 
with  dram  and  half  of  paraffin  of  melting  point 
115.  May  20,  1906.  Agent  deposited  along 
canal  and  at  internal  ring.  One  week  later  no 
pain,  no  tenderness  to  moderate  pressure.  Cord 
somewhat  larger  than  normal  and  epididimus 
thickened  but  not  tender.  Shreds  in  urine. 
Through  interpreter  information  gleaned  that 
epididimus  had  been  somewhat  tender  following 
operation.  History  of  acute  epididimitis  some 
months  before. 


Case  10. 

Case  10  A.  J. — Patient  first  consulted  at  Har- 
vey dispensary.  Treated  for  urethral  stricture 
by  internal  urtehrotomy.  Subsequently  referred 
to  A.  C.  C.  Disp.  for  treatment.  Developed 
acute  appendicitis  and  operation  for  removal 
after  development  of  abscess.  Abscess  drained 
and  healing  of  abdominal  incision  imperfect 
leaving  hernial  protrusian  internally  and  near 
superior  angle  of  scar.  Injected  with  seventy 
minims  of  paraffin,  115  melting  point,  on  Aug.  2, 
1906.  Xo  pain  following  injection,  no  discolora- 
tion, and  no  recurrence  over  a  year  and  a  half 
after  operation. 


CONCLUSION. 

These  eases  represent  the  ten  first  which 
were  seen  subsequent  to  injection.  Cases  which 
were  injected  and  Avhich  did  not  return  subse- 
Cjuent  to  injection  have  not  been  included  as 
they  would  be  of  no  value  in  estimating  as  to 
the  usefulness  of  this  method.  In  no  instance 
has  an  ill  conseciuence  been  suffered  which 
would  cause  the  patient  to  seek  surgical  aid  else- 
where, or  at  least  no  case  has  come  to  the  knowl- 
edge of  the  author  directly  or  indirectly. 

Large  hernia  which  have  gone  unreduced  for 
years  have  not  been  treated  by  injection  and 
discretion  demands  that  for  some  time,  or  until 
injection  treatments  have  been  practiced  upon 
many  patients,  that  large  ruptures  which  have 
been  outside  the  abdomen  for  long  periods  be 
left  to  the  surgeon  or  be  injected  only  by  prac- 
titioners capable  of  doing  the  cutting  operation 

79 


in  the   advent   of  the  failure  of  the   injection 
treatment.  ^ 

The  author  for  his  own  part  has  felt  no  hes- 
itancy in  injecting  cases  which  promised  a  fair 
degree  of  success,  realizing  full  well  that  un- 
toward symptoms  of  a  local  character  may  be 
overcome  by  free  dissection,  removal  of  the 
paraffin  and  restoration  of  the  inguinal  canal 
by  the  usual  surgical  means. 


83 


CONTENTS 


PAGE 

Foreword 3 

Preparation  of  the  skin u »  10 

Preparation  of  the  hands  of  the  operator   .  „ 12 

Preparation  of  the  syringe 15 

Preparation  of  the  paraffin IH 

Posture  of  patient  for  injection. . , c  o . . . .  .  23 

Skin  infiltration  to  permit  of  insertion  of  long  needle 

without  undue  pain   25 

The  effect  of  paraffin  compounds  upon  the  tissues 27 

The  immediate  after  effects  of  the  paraffin  injections  30 
The  precaution  used  to  prevent  throwing  of  paraffin 

into  the  circulation 32 

Factors  to  be  considered   in    dealing  with   inguinal 

hernia . . 35 

Where  the  injection  should  be  placed 39 

The  amount  of  paraffin  to  be  introduced  in    a   given 

case 42 

Technic  to  be  used  in  injecting  inguinal  hernia .  44 

The  injection  of  femoral  hernia 51 

Injection  of  umbilical   hernia 53 

Case  reports 69 


81 


Cosmetic   Surgery 

The  Correction  of  Featural  Imperfections 

BY 

CHARLES  C.   MILLER,   M.  D. 

Very  excellent  and  practical.       Southern  Tractitioner. 
Will  fill  a  distinct  place  in  the  realm  of  surgery. 

Cleveland  [Medical  Journal. 
Covers  a  most  important  field  of  special  surgery. 

Southern  Clinic. 
The  booV  is  certainly  a  valuable  contribution  to   the 
subject.  Optkalmology. 

Has  gone  far  beyond  the  limits  of  surgery  as  under- 
stood and  practiced  in  this  countr}^ 

"British  Medical  Journal, 
The  author  has    done    the   profession    a   service    in 
offering  his  work  upon  the  subject. 

Yale  Medical  Journal. 
The  book  furnishes  in  an  extremely  convenient  and 
accessible  form  much  information  concerning  a  branch 
of  surgery  which  is  dail}'  growing  in  impartance  and  in- 
terest. Military'  Surgeon. 
Dr.  Miller  has  made  out  a  good  case  as  to  why  the 
regular  surgeon  should  give  this  question  some  consider- 
able attention  rather  than  leave  such  things  to  the  char- 
latan and  quack. 

Canadian  Journal  of  OAedicine  and  Surgery. 

160  Pages.  93  Illustrations.  Price  $1.50. 


RD621 


Miller 


M61 


J0t  l^  1955 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD621IV161  1908  C.1 

The  cure  of  rupture  by  paraffin  iniectio 


2002099691 


